VADM Wlilard P. Arentzen, MC, USN
Surgeon General of the Navy
RADM H.A. Sparks, MC, USN
Deputy Surgeon General
Director of Public Affairs
ENS Richard A. Schmidt, USNR
Virginia M. Novinski
Nancy R. Keesee
Contributing Editor-in-Chief: CDR E.L.
Taylor (MC); Aerospace Medicine:
CAPT M.G. Webb (MC); Dental Corps:
CAPT R.D. Ulrey (DC); Education: LT
R.E. Bubb (MSC); Fleet Support: LCDR
J.D. Schweitzer (MSC); Gastroenterol-
ogy: CAPT D.O. Castell (MC); Hospital
Corps: HMCM H.A. Olszak; Legal:
LCDR R.E. Broach (JAGC); Marine
Corps: CAPT D.R. Hauler (MC); Medi-
cal Service Corps: CAPT P.D. Nelson
(MSC); Nephrology: CDR J.D. Wallin
(MC); Nurse Corps: CAPT P.J, Elsass
(NC); Occupational Medicine: CDR J.J.
Bellanca (MC); Preventive Medicine:
CAPT D.F. Hoeffler (MC); Research:
CAPT J. P. Bloom (MC); Submarine
Medicine: CAPT J.C. Rivera (MC)
POLICY: U.S. Navy Medicine is In official publication
of the Navy Medical Department, published by the Bureau
of Medicine and Surgery. It disseminates to Navy Medical
Department personnel official and professional information
relative Co medicine, dentistry, and the allied health sci-
ences. Opinions expressed are those of the authors and do
not necessarily represent the official position of the Depart-
ment of the Navy, the Bureau of Medicine and Surgery, or
any other governmental department or agency. Trade
names are used for identification only and do not represent
an endorsement by the Department of the Navy or the Bu-
reau of Medicine and Surgery. Although U.S. Navy Medi-
cine may cite or extract From directives, official authority for
action should be obtained from the cited reference.
DISTRIBUTION: U.S. Navy Medicine a distributed to
active-duty Medical Department personnet via the Standard
Navy Distribution List. The following distribution is author-
ized: one copy for each Medical, Dental, Medical Service
and Nurse Corps officer; one copy for every 10 enlisted
Medical Department members. Requests to increase or de-
crease the number of allotted copies should be forwarded to
U. S. Navy Medicine via the local command.
CORRESPONDENCE: All correspondence should be
addressed to: Editor. U.S. Navy Medicine. Department of
the Navy. Bureau of Medicine and Surgery (Code 0010),
Washington, D.C 20372. Telephone: (Area Code 202) 254-
4253. 254-4316, 254-4214; Autovon 294-4253. 294-4316, 294-
4214. Contributions from the field are welcome and will be
published as space permits, subject to editing and possible
The issuance of this publication is approved in accordance
with Department of the Navy Publications and Printing
Regulations (NAVEXOS P-35>.
Vol. 69, No. 11
1 From the Surgeon General
2 Department Rounds
New Hospital Corps Division Director Named . . . Dr. Kaires Gets
4 Notes and Announcements
6 Special Report
The Surgeon General's 10th Annual Specialties Advisory Confer-
ence and Committees' Meeting — First Plenary Session
6 Surgeon General's Keynote Address
VADM W.P. Arentzen, MC, USN
9 OP-093: A Status Report
CAPT EM. Bryant, MSC, USN
12 Contingency Planning
CAPT J.J. Quinn, MC, USN
14 Medical Readiness for Operational Contingencies
RADM H.A. Sparks, MC, USN
17 Medical Department Personnel: Issues and Initiatives
RADM R.F. Milnes, MC, USN
19 Medical Corps Manpower
CAPT J. E. Can, MC, USN
25 Budget Update: Dollars, Facilities, Equipment
RADM A. C. Wilson, MC, USN
28 Scholars' Scuttlebutt
Your Reimbursements: Speeding the Process
29 BUMED SITREP
COVER: Behind this 290-pound rig is LCDR Pamela A. Kaires (MC),
the Navy's first woman to dive to depths of 300 feet — and the first
ever to qualify as a submarine medical officer (see page 3). Photo by
PH2 Jim Preston.
From the Surgeon General
Various specialists on our Medi-
cal Department team are highly
lauded from time to time. General-
ly, attention is drawn to individuals
operating in a primarily clinical
mode. But when the overall Navy
mission is examined, we must rec-
ognize that we have unsung spe-
cialists among us: those engaged in
The readiness and proper func-
tioning of the forces afloat is the
"name of the game." But the oper-
ational medicine specialist stands in
the front line. He or she is unique
and has no precise parallel in the ci-
vilian community. Needless to say,
the flight surgeons and undersea
physicians are in the vanguard — but
so, too, are the aviation and diving
physiologists, and the aerospace
and submarine medical technicians,
both officer and enlisted, who back
up those physicians, and without
whom those physicians could not
I salute all of you and wish to
make known to you publicly that we
recognize and appreciate your tal-
ents and dedication.
I am taking a personal interest in
programs designed to augment the
attractiveness of your career pat-
terns and your professional pro-
gress. I feel strongly that you are an
integral part of the medical team.
Those of us who are not primarily
in operational medicine might well
consider not only the contribution to
be made, but the rewards to be har-
vested, by joining your ranks.
And we should see to it that
operational medicine is no longer
the repository of the unsung.
Vice Admiral, Medical Corps
United States Navy
Volume 69, November 1978
New Hospital Corps Division Director Named
CAPT Roy W. Tandy (MSC) has
been named director of the Navy
Medical Department's Hospital
Corps Division. He reported on
board at BUMED in late July, after
last serving as director of adminis-
trative services at NRMC Great
CAPT Tandy entered the Navy as
a seaman recruit in 1951 and was
commissioned an ensign in 1957.
His naval service includes assign-
ments aboard the USS Staten Is-
land, an icebreaker in the Arctic; as
an independent duty corpsman
aboard the minesweeper USS For-
tify; as a data-processing officer at
Bethesda and San Diego; and as
administrative/supply officer in
Okinawa with the Marines during
the Vietnam conflict. More recently,
he established the naval medical
region in Hawaii and served as its
first executive officer before his ap-
pointment as DAS at Great Lakes.
"The Hospital Corps is relatively
healthy and becoming more so each
day," says CAPT Tandy. "There
are, right now, 23,271 Hospital
Corps billets around the world,
filled by 22,026 corpsmen. If we can
fill the school seats that we have, we
should reach 100% in the next fiscal
The Hospital Corps has taken a
number of new initiatives with re-
spect to training, including develop-
ment of a respiratory care techni-
cian package that will provide seats
for selected corpsmen in the Army
School at Fort Sam Houston, begin-
ning next year.
Another area under study is
management training for the E-8
and E-9 communities. "There has
been no formal training in manage-
ment for these people, nor have
there been openings in middle-
management positions," CAPT
Tandy says. "One of the initiatives
of the Surgeon General is to bring
the E-8 and E-9 into middle-man-
agement positions at our medical
In the Hospital Corps, as else-
where in the Navy, much planning
is being devoted to making full use
of the talents of women — and to
preparing for their service aboard
Navy ships and in other "new" as-
"Young women in the Hospital
Corps are beginning to enter fields
that have been traditionally male,
such as medical repair," says CAPT
Tandy. "I'm very pleased with that
and want to encourage it. We're in-
creasing the basic ratio of females
As to problems for the Hospital
Corps, the biggest one just now, he
says, is "getting students into the
schools. If we don't have enough
qualified volunteers, we can't bring
our technical specialties up to
strength. In the most recent selec-
tions, we were able to fill most of
the school seats with reasonably
well-qualified people, but pharmacy
and submarine medicine are des-
perately short of volunteers." (A
recent increase in bonus pay for
submariners should help that cate-
gory, he notes.)
The retention rate for hospital
corpsmen at the first-term decision
point is currently 22.1% — much
better than that of the recent past —
but there's room for further im-
provement, says CAPT Tandy. "We
need to offer these people career
patterns that meet their needs. We
recognize the need, and we're
working on it."
Of his new job, he says: "I'm
pleased and to some extent flattered
to be here. I'm also somewhat
amazed by my misconceptions of
the Bureau — and I suspect the mis-
conceptions of many field officers —
as to its omnipotence. We are not a
Navy unto ourselves, but part of the
U.S. Navy, and I'm convinced that
awareness may be more acute here
than in the field.
"There seems to be a tendency in
the field to think that BUMED is all-
powerful. But we vie for the same
assets as the rest of the Navy.
There's no cornucopia of dollars and
people here at the Bureau."
U.S. Navy Medicine
Dr. Kaires Gets Her Dolphins
At the Naval Undersea Medical
Institute, Groton, Conn., LCDR
Pamela A. Kaires (MC) recently
became the first woman ever to re-
ceive the twin dolphin pin that sig-
nifies qualification as a submarine
The award ceremony, held in late
September, marked LCDR Kaires'
successful completion of a rigorous
six-month course in submarine
medicine, covering biomedical dis-
ciplines as applied to the submarine
and diving environment.
The course included eight weeks
of instruction at the Navy School of
Diving and Salvage, in Washington,
D.C., during which Dr. Kaires be-
came the Navy's first woman to dive
to depths of 300 feet, using the 290-
pound Mark V mixed-gas diving
Dr. Kaires, a graduate of The
George Washington University
Medical School in the nation's capi-
tal, completed her internship and
her residency in internal medicine
at NRMC San Diego, She came by
For Dr. Kaires, diving school was one step along the rigorous way to her dolphins.
her interest in Navy medicine natu-
rally, since her father — RADM
Anthony K. Kaires — is a retired
Navy dentist and her sister — LT
Cynthia Kaires — is a Navy nurse.
Next month, Dr. Kaires will leave
New London for a new assignment
at the Naval Regional Medical
Clinic, Hawaii, with additional duty
to Submarine Squadron Seven at
Pearl Harbor. Though current law
prohibits her from actually serving
aboard a submarine, she sees many
possibilities ahead for challenging
work in her chosen specialty, and
looks forward particularly to in-
volvement in hyperbaric research.
Photo bv PH2 Jim Preston
Volume 69, November 1978
Notes & Announcements
In memoriam . . . RADM Alfred W. Chandler, DC, USN
(Ret.), former assistant chief of the Bureau of Medicine
and Surgery for Dentistry and chief of the Dental Divi-
sion, died 24 Sept 1978, at age 88.
RADM Chandler was born in Newport, R.I., and
graduated from the University of Pennsylvania Dental
School in 1915. He enlisted in the Navy in 1917, one
week after the United States declared war on Germany,
and subsequently served as senior dental officer at U.S.
naval bases and overseas, as well as at the U.S. Naval
Academy, Annapolis, Md.; Naval Training Center, San
Diego, Calif.; and U.S. Naval Hospital, St. Thomas,
RADM Chandler was a member of the first dental
officer class at Washington's Naval Dental School. In
1923, after completing postgraduate work at North-
western University, he became head of the prosthetic
and operative departments at the Naval Dental School.
In 1947, RADM Chandler, a specialist in prosthodon-
tics, became assistant chief of the Bureau of Medicine
and Surgery for Dentistry and chief of the Dental Divi-
sion. He was responsible for establishing the first Navy
schools for dental technicians at Bethesda, Md., Great
Lakes, 111., and San Diego, Calif. He also was responsi-
ble for establishing dental facilities in all ships and sta-
tions having dental personnel. He became the dental
inspector general in 1 948 and held this position until he
retired in 1952.
RADM Chandler was a member of the Capitol Clinic
Club, American Denture Society, and American Dental
Association; a diplomate of the American Board of
Prosthodontics; and a fellow of the American College of
Dentists. He held the Legion of Merit and the Hayden-
Harris Award for his contributions to the history of
dant, Eleventh Naval District, should be submitted to:
Commandant, Eleventh Naval District (Code 37), San
Diego, Calif. 92132. Applications for other dental con-
tinuing education courses should be submitted to: Com-
manding Officer, Naval Health Sciences Education and
Training Command (Code 5), National Naval Medical
Center, Bethesda, Md. 20014. Applications should
arrive six weeks before the course begins.
Continuing education for Navy nurses . . . The Naval
Health Sciences Education and Training Command will
sponsor the following continuing education course for
Anesthesia Update (30 contact hours)
5-7 Feb 1979
Designed for Navy nurse anesthetists to present new concepts in
methods and techniques in the field of anesthesia.
The course is open to Nurse Corps officers not cur-
rently assigned to an oversea billet. However, nurses
assigned to Argentia, Newfoundland; Bermuda; Guan-
tanamo Bay, Cuba; Keflavik, Iceland; and Roosevelt
Roads, Puerto Rico, who have served at least six
months on active duty, may apply. The course is also
open on a space-available basis to Nurse Corps officers
of the inactive Reserve.
Nurse Corps officers wishing to attend the course
should apply to the Naval Health Sciences Education
and Training Command (Code 7), National Naval
Medical Center, Bethesda, Md. 20014, following pro-
cedures set forth in the BUMED Instruction 4651.1
series. Applications should be submitted four to six
weeks before a course begins.
Dental continuing education courses . . . The following
dental continuing education courses will be offered in
National Naval Dental Center, Bethesda, Md.
Periodontics 5-7 Feb 1979
Fixed Partial Dentures 26-28 Feb 1 979
Eleventh Naval District, San Diego, Calif.
Complete Dentures 20-22 Feb 1979
U.S. Army Institute of Dental Research, Walter Reed
Army Medical Center, Washington, D. C.
Advanced Clinical Oral Pathology 5-8 Feb 1979
Requests for courses administered by the Comman-
AFD? courses offered . . . The Armed Forces Institute of
Pathology will offer the following courses:
Genitourinary Pathology 29 Jan -2 Feb 1979
This course consists of a basic and comprehensive survey of the
pathology of surgical diseases of the kidney, ureter, bladder, pros-
tate, testis, penis, and urethra. The course is designed for urologists
and will be presented by lectures, demonstrations, and the study of
Applicants should be members of the Medical Corps
of the Armed Forces or other federal services who are
board eligible or certified urologists. Applications from
qualified civilians will be considered on a space-avail-
U.S. Navy Medicine
Seminar and Workshop — Histopathology Techniques 5-9 Feb 1979
The wet workshops will consist of bone techniques, eye techniques,
brain techniques, and special staining techniques. These workshops
will be held during the first two and half days. Selective training will
be offered on Wednesday afternoon to include cryostat, kidney bi-
opsy, spirochete staining, lymph node procedures, preparation and
application of the H & E stain, knife sharpening, and the use of
plastic (diatex) for tissue section transfer. The remaining day and a
half will consist of lecture sessions.
Applicants should be members of the Armed Forces
or other federal services. Individuals must have at least
one year's experience in a histology laboratory, and the
training request must be made by the sponsoring
pathologist. Use of a special application form is essen-
tial. This form can be obtained by writing The Armed
Forces Institute of Pathology, Washington, D.C. 20306,
ATTN: AFIP/EDZ. Civilian applications will be con-
sidered on a space-available basis.
Pathology of Genetic Disease 12-16 Feb 1979
The genetic aspects of various diseases due to point mutations and
chromosomal aberrations will be discussed, using AFIP- accessioned
case material to illustrate the pathologist's role in diagnosis. The
pathologic effects of many of these diseases in specific organ systems
will be reviewed. Lectures will cover the correlation of the clinical and
laboratory features with the morphologic alterations of typical exam-
ples of diseases due to trisomy aberrations, sex chromosomal
anomalies, genetic abnormalities in sexual differentiation, autosomal
and x-linked dominant and recessive point mutations. Specific
genetic pathologic case problems accessioned at AFIP will be pre-
sented to participants and their resolutions discussed.
Applicants should be members of the Medical Corps
of the Armed Forces or other federal services who are
board eligible, or certified in pathology or other special-
ties, with an interest in genetic diseases. Other military
professional personnel and qualified civilians may
apply on a space-available basis.
Further information may be obtained by writing to
the Director, Armed Forces Institute of Pathology,
ATTN: AFIP/EDZ, Washington, D.C. 20306.
Cold weather medicine and NBC warfare training . . .
Two new training programs developed by the Naval
Health Sciences Education and Training Command are
now available to Medical Department personnel.
• Cold Weather Medicine provides the necessary
knowledge to operate effectively in areas of severe cold.
The program is a self-study or classroom course con-
sisting of instructional materials, objectives, lecture
outlines, a glossary, an annotated bibliography, and an
information source list. The format and contents are
designed to help users choose portions relating to their
professional and operational needs.
• Medical Considerations of Nuclear, Biological, and
Chemical Warfare provides information on handling,
treating, and protecting personnel from the effects of
NBC weapons. This program is a classroom course and
consists of tasks, objectives, lecture outlines, a bibliog-
raphy, and a general information section.
Requests for these programs should be forwarded to:
Commanding Officer, Naval Health Sciences Education
and Training Command (Code 21), National Naval
Medical Center, Bethesda, Md. 20014.
Infectious disease course . . . The second annual Uni-
versity of California, San Francisco course on Infectious
Diseases in Clinical Practice will be held 27 Jan-3 Feb
1979 in Sun Valley, Idaho. The course will emphasize
clinical management and prevention of viral, bacterial,
and mycotic infections, with emphasis on recent ad-
vances in diagnosis and treatment. The course should
be of interest to general and family practitioners, ob-
stetricians-gynecologists, internists, pediatricians, and
general surgeons. There will be lectures and specialty
seminars. A comprehensive syllabus will be distributed
For further information write to: Extended Programs
in Medical Education, University of California, San
Francisco, Room 569-U, Third and Parnassus Ave., San
Francisco, Calif. 94143. Telephone (415) 666-4251.
Clinical cytopathology postgraduate course . . . The
20th Postgraduate Institute for Pathologists in Clinical
Cytopathology will be given 23 April-4 May 1979 at The
Johns Hopkins University School of Medicine and The
Johns Hopkins Hospital, Baltimore, Md. The two-week
program is designed for board-certified or -qualified
pathologists and will provide an intensive refresher
course in all aspects of clinical cytopathology, with time
devoted to new techniques and special problems.
Topics will be covered in lectures and informal confer-
ences, and discussed over the microscope. A set of
slides with text will be sent on loan to each participant
for home-study during March and April before the
Institute. Credit hours will be 120 in AMA Category 1,
Applications should be received before 28 Feb 1977.
For more details write to: John K. Frost, M.D,, 610
Pathology Building, The Johns Hopkins Hospital, Balti-
more, Md. 21205.
Volume 69, November 1978
The Surgeon General's 10th Annual Specialties
Advisory Conference and Committees' Meeting
This conference was held 12-15 September 1978 in
Arlington, Va. Following is a report of the first plenary
session of this annual conference. A concluding report
will appear in the December issue of U.S. Navy Medi-
This report represents an edited (sometimes para-
phrased or abbreviated) version of the remarks and
presentations of specified individuals. Their comments
do not necessarily reflect official views of the Navy
Department or of the naval service at large. — Ed.
Surgeon General's Keynote
VADM W.P. Arentzen, MC, USN
Surgeon General of the Navy
At SAC IX, I devoted my remarks to a general state-
ment of our major problem areas and some of the ini-
tiatives we had taken to combat them. I stated my con-
fidence in our ability to confound our critics. I remain
I will speak of some problems this morning, but first I
want to share with you my perceptions of some of the
forces impacting on us as a Medical Department.
Shortly after leaving the Office of the Secretary of
Defense, James R. Schlesinger observed that, for
Americans, security has been too widely viewed as a
' ' given . ' ' Too little is it appreciated that the stability we
still enjoy is a reflection and legacy of past American
involvement and active leadership. He went on to de-
scribe the more immediate invisible factors, such as the
altered psychological stance of the United States, which
is apparently withdrawing from the burdens of world
leadership, with a resultant change in our national
This change in national defense policy has placed us
in an era of competition for resources unmatched in our
experience or in that of our predecessors. The size of
our defense budget, although increasing in terms of
total billions of dollars, has decreased in terms of real
purchasing power, under the pressure of inflation. At
this time, relative to the gross national product, our
expenditure for defense is somewhat less than 6 % .
The Navy and its sister services are undergoing ex-
actly the same pressures. We are being asked to do
more and more with less and less. This decrease in
dollars with which to buy and run the ships we know we
need has had some profound effects. As short a time
ago as 1968, the Navy had 976 ships in commission. As
of two months ago, we had 485 ships in our active fleet.
Building costs are staggering. A carrier costs over $1
billion. A fighter plane costs around $20 million. A
strike cruiser will cost between $700 million and $900
The health care environment, military and civilian, is
undergoing similarly inflationary times. In the past
year, the total health care bill for the nation was well
over $100 billion. This approaches 10% of the gross
national product. The government's share of this bill is
approximately $50 billion. Inflationary pressures, as
well as expansion of social programs, could double or
even triple those already huge figures within the next
10 or 20 years.
As a result, nationally we see a continuing trend
toward federal management of the nation's health care
industry, as evidenced by increased structuring of the
organization of health services delivery.
Public Law 93-641 gave impetus to this structuring by
establishing local, state, and regional entities within
which federal and state funds would be dispensed
U.S. Navy Medicine
and managed. Similarly, public law has provided
direction for the limitation of federal participation in
capital expenditures, as well as a mechanism for moni-
toring the quality of care under the aegis of professional
standards review organizations. The passage of Public
Law 94-44, with its emphasis on the delivery of primary
care, provides the government for the first time with an
obligated, controllable pool of professional health care
providers. Implementation of the Occupational and
Safety Health Act has provided teeth to federal efforts
to control the safety of the work environment, but has at
the same time created an expanded requirement for
professionals and money to support this effort.
For the Navy, the cost of health care this year will
exceed $1 billion. One out of every six commissioned
officers in the Navy is in the Medical Department. Is it
any wonder that we are being analyzed, scrutinized,
and directed to make every dollar count?
In view of these changes in our environment, what
have we done? Well, for too long we have kept our
heads in the sand. Instead of coming to terms with any
of the real issues confronting military medicine, we
spent much of our time waging symbolic power
struggles which prevented anyone from making deci-
sions about anything.
In 1973, the draft ended, and the era of the all-volun-
teer force began. Since 1954 and the beginning of the
Berry Plan days, we had welcomed up to a thousand
superbly well-trained physicians every year. We used
them and let them go their way. After all, another
thousand would come next year.
What a waste! Almost one third of the Navy Medical
Corps turned over each year, and no one recognized the
waste for what it was.
We did this same thing with our other communities:
dentists, Medical Service Corps officers, nurses, and
corpsmen. With the draft, our supply was limitless.
What need was there to conserve manpower, develop
stability, train to requirements, or retrench and develop
the initiatives needed for a truly responsive and re-
sponsible health care system?
Then it stopped. The draft was over. In a flurry of
self-righteous excitement, we developed a spate of new
programs designed to solve our problems. Each service
had its own, but we still hadn't sensed our environ-
ment. We still had not learned our lesson: that training
was expensive, and that we could no longer afford the
luxury of going it alone — in short, that we were in a dif-
ferent era. Manpower was now expensive, approaching
76% of our DOD budget. These programs failed the
scrutiny of the analysts and are gone.
Personnel is only one of our problems. Can we con-
tinue to justify two hospitals in the same city, doing the
same thing? Can we justify two separate medical sys-
tems on the same island?
Social economists — the analysts within and without
— have recognized us for what we are: a potential test-
ing ground for their systems and theories of health
care, in which will be the shape of our national health
care systems in the future. We are perfect for their use.
We have a good health care delivery system in the mili-
tary. We are a significant national asset. We offer a
ready, prepared, responsive, sustainable force to be
mobilized in time of natural crisis or conflict. If we
didn't exist, we would have to be invented. We serve as
a model, as the nation moves ever closer to the enact-
ment of national health insurance.
Because we are a federal agency, we must and
should be responsive to the government's command.
But just because of that, we must be especially careful
not to become embroiled in pointless philosophic con-
troversy or allow ourselves to be used as a test tube for
every new notion. If we are to be the tail that wags the
dog of the civilian medical sector, let us wag it with very
President Carter has stated his intention to introduce
legislation establishing a national health insurance
program of some sort during this Congress. Foresight
and effective planning will help us avoid the paralysis
and confusion that are certain to be associated with
such a major change in American medicine.
Our mission is unique. We must protect that unique-
ness. Most of modern medicine is the same wherever
we go, but there are some things in the military that are
different, and they must be preserved. Perhaps we
have placed too much emphasis on how similar military
medicine is to civilian medicine.
To a degree, we have been the authors of our own
problems. Our patients have been educated by us to
expect miracles in every situation. Our patients have
forgotten how to be sick — antibiotics for every fever;
mood elevators for every slight depression or fear of
one; sleeping pills whenever sleep is delayed for a few
minutes; organ transplants as one's own organs wear
out. How can we blame our patients? And when esca-
lating demands cannot be met, a bit more bloom comes
off the rose.
Competition for available resources will become ever
keener, the conflicting imperatives ever more pressing.
Success in some eyes will be measured more and more
by compromise. We must be ever watchful in that re-
What does tomorrow hold? What will be the environ-
ment in which we will be working?
I think that certain trends now visible will continue.
Present indications are that the Department of De-
fense's role in policy development and resource
management will expand. Under the aegis of the De-
partment of Defense, health care regionalization will
become more firmly established as a mechanism within
Volume 69, November 1978
which the military health care system will work. I
expect that there will be increasing pressure for, and
movement toward, integration of the entire military
health care system with the civilian sector.
There is little question that zero-based and capitation
budgeting will serve as the basis for future funding.
Much of this effort will probably stem from an enroll-
ment system for all classes of our beneficiaries. The
general delivery of health care will change. More of our
efforts will be directed toward ambulatory health care.
The Surgeons General are meeting regularly to
identify our commonalities, share our resources, de-
velop constructive supporting programs, and eliminate
duplication. Equipment purchases are being coordi-
nated. Programs are being directed toward the rightful
dominant claimant, and joint training efforts are being
initiated. We are placing increased emphasis on in-
volving our facility managers in the decision- making
process and providing them with the needed informa-
tion and systemwide awareness required. Increased
emphasis is being, and must be, placed on evaluation
systems and indicators to tell us at each level how we
are doing. We must emphasize cost containment and
cost effectiveness, as well as quality of care, if we are to
compete effectively. We must increase our ability to
translate health care demands into programs and al-
location of doctors, dollars, and personnel.
What does all this mean for physician managers in
our system? It will require innovative thinking. It will
require inventive management. As health care general-
ly comes under relentlessly greater government control
and review, the opportunity to work and to exert an
influence on the frontier should be an exciting area for
imaginative, creative professional growth.
But as much as we need physician managers, we
need leaders more. Systems can be managed. People
must be led. It is in this latter area that I am uneasy.
During the past 12 months I have visited a large
number of our facilities, from Japan to China Lake. I
have been disturbed by some of the things I have seen,
pleased by even more. But too many times I see
evidence of resignation and malaise — what William
Raspberry has called "big-picture paralysis."
It is too easy to say that the problem is so immense,
the difficulties are so huge, that one's own efforts don't
matter. If we paint the picture big enough, we can paint
ourselves right out of any part of the solution. The
physician shortage, budget cuts, deteriorating facili-
ties, and the crush of patients to be cared for are all big
problems. But even so, individual decisions can have
important results for individuals, even if they don't
register statistically. Every corps man who reenlists as a
result of your effort is important. Every patient who is
satisfied with his clinic experience as a result of your
compassion is important. Every physician who extends
as a result of your example is important. They are all
The point is not to relieve the Bureau or the Navy of
the big-picture responsibilities. The point is that indi-
vidual effort matters also.
Another attitude which concerns me greatly is less-
than-universal understanding and support of our
mission. Support of the operating forces is the reason
we exist, and service of these forces should be our
highest calling. I have spoken with our scholarship stu-
dents and find general understanding of the operational
commitments of the Navy Medical Department — even
enthusiasm. This is reinforced by the six- week OCS
course at Newport. But much of that is dissipated dur-
ing the GME-1 year, partly as a result of natural situa-
tional inertia; partly because there are few visible role
models; and, most disturbing of all, partly because of
overt discouragement on the part of staff physicians at
our teaching hospitals — including program chairmen.
It is inconceivable to me that such action on the part
of career physicians — that such failure to understand
why we are here — can take place. That attitude must be
One of my major goals as Surgeon General has been
the removal of barriers between hospital-based and
force- based personnel. It is clear that we have not come
as far along that road as I would like. I need your indi-
vidual efforts in this endeavor.
I am concerned about our teachers. Even though
numbers of physicians will not be a problem by 1981 or
1982, the availability of good teachers, particularly in
the subspecialties, will be a problem. We must retain
them. We must retain every one of you in this room.
Without you as role models, we won't keep those we
Identify potential teachers early. Encourage their
participation in your training programs. Solicit their
ideas. While the generalist is of great value to the
Navy, we cannot afford to become a corps of nothing
Some individual efforts are beginning to pay off. Ex-
tension of medical officers is better this year than last,
for the same time frame. During last year's SAC, we
were predicting a physician shortfall between 250 and
400. On 10 October 1978, that shortfall will be 169. That
is a shortfall of 4.5%, considerably better than those of
our sister services. Even that number is too large, but it
is better than we had feared.
We have received additional funds for conference
travel — not enough, but more than before. Funds for
equipment purchases continue at significantly higher
levels. Our scholarship program is fully subscribed.
Extension of the existing special pay legislation has
been approved, and a new bill to improve and stabilize
the special pay provisions has been introduced.
U.S. Navy Medicine
Some intangibles are beginning to emerge. The
quality of volunteers seems definitely higher than in the
recent past. The level of interest in military medicine
appears to be higher. The Uniformed Services Univer-
sity of the Health Sciences is a going concern, and we
do have allies now. And these allies are beginning to be
heard, in the Congress, in the Department of Defense,
and in the Navy.
I am convinced that facing the facts is always healthy
and the way of wisdom, I pledge to you my intent to
continue to do battle and to yield ground most grudg-
Training is our life's blood, and I pledge my full sup-
port to that effort. I remain confident; I remain proud.
Someone once said, "You are as young as your faith,
as old as your doubt; as young as your confidence, as
old as your fear; as young as your hope, as old as your
despair. When your heart is covered with the snows of
pessimism and the ice of cynicism, then and only then
are you grown old."
I am feeling younger every day.
OP-093: A Status Report
CAPT E.M. Bryant, MSC, USN
Office of the Surgeon General
During these past 10 years of SAC meetings, we've
seen and experienced numerous changes in our Navy
Medical Department, many of which were driven by
external forces. As a matter of fact, in the areas of re-
source and organizational change, the number of ex-
ternally driven "improvements" has made us wonder
whether or not one more improvement might lead to
Today my purpose is to report to you another change,
this time organizational. However, we are excited by
this change, because it makes the Surgeon General an
official member of the top-line management team:
OPNAV (Echelon 1). It gives him resource sponsorship
for all medical and medical training program elements,
and it assigns him functional task sponsorship for medi-
cal, Navy- wide.
Briefly, that identifies OP-093. Actually, OP-093 is
the Office of the Surgeon General in the Pentagon. The
Surgeon General becomes director of a major support
office (DMSO) in the Chief of Naval Operations organi-
One may ask, Why an OP-093 after all these years?
How is it structured? And what is its status today?
In September 1977, the Vice Chief of Naval Opera-
tions expressed concern about several aspects of the
Navy health care services system. Among these con-
cerns were the medical organizational relationships
with Navy; the fact that execution of health services was
being directed by the Surgeon General with assistance
from the staff of BUMED, a second echelon command;
and the fact that the responsibility for health care ser-
vices at the first echelon level — that is, OPNAV — was
As a result, the VCNO tasked RADM Synhorst (Ret.),
OP-09E, as the study director to review the organiza-
tion for health services. The study was completed 1 Jan
1978, and the major findings supported the concerns of
the Vice Chief. There were 16 medical billets scattered
throughout 13 OP codes, with no central coordination.
Of particular note is the fact that, by public law, the
official title of the Chief of the Bureau of Medicine and
Surgery is "Surgeon General." He is a second echelon
commander. This placement of the Navy Surgeon Gen-
eral differs from that of the Army and Air Force Sur-
geons General. They are assigned to the Chiefs of Staff
and function on the department headquarters staff.
Generally, the service Surgeons General are per-
ceived by higher authority to be the senior medical pro-
fessionals on the headquarters staff, whether this
placement exists or not. Over the years, medical func-
tions in the Navy which should have been performed by
the CNO staff were accomplished by BUMED. Fre-
quently, recommendations on policy matters were
made by BUMED without CNO awareness. More fre-
quently, authorities above the CNO communicated
directly with BUMED without the CNO's being in-
So the answer to question number one — Why an OP-
093? — can be summarized as follows:
CNO needed a central organizational unit to coordi-
nate policy, guidance and direction, and professional
and technical advice on all health-care-related pro-
grams. In addition, this central office would be the focal
Volume 69, November 1978
OFFICE OF THE SURGEON GENERAL
OP - 093
DEPUTY SURGEON GENERAL
OP - 093B
093A EXEC ASST
093C SPECIAL ASST FOR
OP - 930
HD PROGRAMMING &.
HD LOGISTICS <fc MEDICAL
HD DOD &. LEGISLATIVE
OP - 931
point for dealing with higher authority, for sponsorship
of resources, and for appraising health care efforts
The second question was, How is OP-093 structured?
VCNO memo of 11 April 1978 directed establishment
of a new DMSO— OP-093— to be entitled the "Office of
the Surgeon General." Figure 1 shows that organiza-
tion. In addition to the Office of the Surgeon General,
we have two major divisions — a Professional Division
and a Planning/Programming Division — that will oper-
ate in the Pentagon.
This action made explicit that which has always been
implicit: that the Surgeon General is the principal advi-
sor to the CNO on medical program matters.
Specific functions assigned to OP-093 are to:
1. Develop Navy health care program policy and
guidance and provide professional and technical advice
on matters pertaining to naval health care.
2. Coordinate, as a sponsor for designated health
care programs, with other sponsors with regard to
Navy/Marine Corps health requirements.
3. Review and appraise the capability of the Navy
Medical Department to respond to contingencies.
4. Review and appraise the performance of the Navy
Medical Department in safeguarding and protecting
the health of authorized beneficiaries.
5. Act as central point of contact for naval health
care matters involving coordination within OPNAV.
6. Act as central point of contact for health care mat-
ters concerning the Marine Corps.
7. Provide backup for meetings on health care mat-
8. Assist the DCNO for Manpower (OP-01) in the
preparation of plans, policies, and studies pertaining to
Navy medical manpower requirements.
9. Assist the DCNO for Logistics (OP-04) in the
preparation of plans, policies, and studies pertaining to
medical logistical support, including the prepositioned
U.S. Navy Medicine
War Reserve Material Program.
10. Assist OPNAV mission and resource sponsors in
programs that have health care impact.
11. Advise and assist the CNO in exercising com-
mand responsibility over the Bureau of Medicine and
12. Act as mission sponsor for medical.
13. Act as resource sponsor for medical and medical
CHIEF OF NAVAL OPERATIONS
OP-090 DtR, NAVY PROGRAMMING
OP-09B ASST VICE CHIEF OF
OP-093 OFFICE OF THE
OP-OS4 DIR. COMMAND & CONTROL
OP-095 DIR, ASW A OCEAN
OP-O08 INSPECTOR SENERAL
OP-0O9 DIRECTOR OF NAVAL
OP-Q9R DIRECTOR OF NAVAL
DEPUTV CHIEF OF NAVAL
OP-D2 SUBMARINE WARFARE
0P-03 SURFACE WARFARE
OP -04 LOSISTICS
OP-OS AIR WARFARE
OP-06 PLANS, POLICY 4
ED & TRNO
CHIEF OF j
FIGURE 3: Interface Between BUMED and OP-093
OP-093 (SG) Chief BUMED
Coordinate OPNAV efforts Provide background data and
in health care field analysis to OP-093
Develop health care policy Translate and implement
policies to BUMED com-
Focal point for higher
Resource sponsor for medi-
cal and medical training
Appraise health care ef-
Focal point for field activities'
programs and problems
Provide detailed resource
data to support OP-093 re-
Evaluate performance and re-
source utilization of BUMED
training program elements.
Functions 12 and 13 assign to the Surgeon General
those normal CNO staff programming functions of re-
source sponsorship and functional task sponsorship.
Prior to establishment of OP-093, these functions were
assigned to other OPNAV offices.
In his implementation memo of April 1978, the Vice
Chief of Naval Operations assigned OP-093 a number of
specific tasks. I will mention three, just to give you
some notion of our charter and our charge.
First, the Surgeon General will program the medical
resources and present the developed medical programs
to the OPNAV decision-making bodies for the first time
during the POM-81 cycle. Right now, the OP-093 staff
is working with the BUMED and HSETC staffs on de-
veloping and presenting training programs for fiscal
Second, OP-093 is to emphasize, in Defense Health
Council deliberations, medical readiness and contin-
gency requirements for medical support, and is to in-
stitute procedures to keep the CNO and the VCNO
aware of initiatives and developments.
Last, OP-093 will discourage new studies in health
care, pending completion of review and action on past
and current studies. (In a recent point paper, we identi-
fied 280 studies and reviews to the CNO.)
This brings us to our final question: What is the
status of OP-093 today?
I am pleased to report that the life- sustaining equip-
ment has been detached from the OP-093 patient. The
organization is alive and on its own. Our military staff is
assigned and in place, with equipment and telephones,
at the Pentagon on the fourth floor, "B" Ring, Rooms
456-464. The OP-093 team has received enough tasks to
last two years, and new tasks arrive daily.
Figures 2 and 3 show the organizational structure
and the envisioned interfaces between OP-093 and
The Surgeon General (OP-093) is located at Echelon
1 , along with all other directors of major support offices
and Deputy Chiefs of Naval Operations, while the Chief
of BUMED sits at the Echelon 2 level, along with all
other major claimants. The interface envisioned be-
tween OP-093 and BUMED is not unlike that which
exists between OP-04 (the DCNO for Logistics) and the
Naval Facilities Engineering Command. Primarily, the
OPNAV organization operates in the upward arenas,
while the Echelon 2 commands support the OPNAV
organization and manage the field activities.
With medical teams at both of these echelons work-
ing together, and with resource and functional task
sponsorships assigned to OP-093, the Surgeon General
has a greater opportunity to gain visibility for Medical
Department programs and problems, and to obtain re-
sources to meet medical requirements in the future.
Volume 69, November 1978
CAPT J.J. Quinn, MC, USN
Deputy Director of Program Planning and Analysis
BUMED Code 02-1
I intend to address three topics: first, what contin-
gency planning is; second, why it is important; and,
third, how contingency planning should affect the selec-
tion process for specialty training.
BUMED contingency plans are, simply, to use the
resources of the Medical Department to meet the re-
quirements of the operating forces. These require-
ments may range from a need for a single physician to a
need for a surgical team to a need for the total re-
sources of the Medical Department in support of an all-
BUMED has initiated and maintains several pro-
grams to ensure its ability to meet these requirements.
These programs include organizing surgical teams,
training medical regulating teams, maintaining pools of
physicians for duty with the fleet, and requesting funds
for seven 1,000-bed fleet hospitals to provide support
for a major war.
To grasp the importance of contingency planning to
the Medical Department, it is first necessary to under-
stand the Department of Defense planning procedure.
The first and most important point is that BUMED
has neither the responsibility nor the right to create
plans. In the great division of the world into "doers"
and "providers," the Navy Medical Department falls
with the providers. We make plans to support the plans
the doers make. That is, they tell us what they need,
and we make sure they get it. But who are "they"?
The cornerstone of the DOD planning process is a
document called the "Consolidated Guidance," which
is produced by the staff of the Secretary of Defense, on
direction from the President. After Presidential review,
it is published over the signature of the Secretary of
Defense. It directs the services to plan to achieve spe-
cific missions, and provides guidelines which define
These guidelines are followed by the Joint Chiefs of
Staff in formulating the Joint Strategic Capabilities
Plan, or JSCAP. The JSCAP provides an assessment of
the potential enemy threat in each area of the world and
serves as guidance to the commanders in chief of vari-
ous theaters in their formulation of operations plans, or
OPLANS are unconstrained. They specify the re-
quirements which must be met in order for the CINC to
defeat the enemy, and leave it up to the providers to
assure that these requirements are met. It is here that
BUMED and other resource and program sponsors
enter the picture.
Each OPLAN has an associated medical annex as a
part of its logistics section. The medical annex states
the requirements for medical support of that particular
OPLAN. BUMED's responsibility is to review that an-
nex and to devise plans to support it. If, as is often the
case, current Medical Department assets are not ade-
quate to meet the requirements, we must develop pro-
grams to reduce or eliminate the shortfall. (The fleet
hospital is one such program.)
The planning process is mission oriented. It may
seem far afield from our daily activities in the medical
centers, and you may think it remote to your purpose
here. It is not. The Consolidated Guidance makes the
connection, in that it directs the services to determine
their appropriate peacetime sizes by their wartime re-
The following is quoted directly from the Consoli-
The primary mission of the military medical system is to plan, pre-
pare for, and provide medical support for military operations in ac-
cordance with approved planning scenarios. This includes:
A. Health care for active-duty members.
B. Medical support for military contingencies.
C. Sufficient mobilization base for rapid expansion of military
medical capability in the case of major war.
D. Rotation base to facilitate managing the substantial volume of
transfer and training functions inherent in providing medical support
for military forces.
E. Educational and training programs necessary to provide a pro-
fessional environment attractive to well -qualified health profession-
The secondary mission of the military medical system is to provide,
on a space-available basis, care to eligible patients other than active-
The Navy Medical Department is held to these guide-
lines in the planning, programming, and budgeting
system. We must make an annual submission of our
wartime requirements, calculated in accordance with
the current Consolidated Guidance, and must show that
these requirements justify our peacetime size. Our
statements are subjected to intense scrutiny by Depart-
ment of Defense analysts and Government Accounting
Office and Office of Management and Budget staffs.
Insofar as they detect logical flaws, inconsistencies, or
ambiguities in the statements of requirements, they
recommend decrements in our programs.
We face many problems in preparing to fulfill our
mission, not the least of which is that the optimum spe-
cialty mix for the treatment of our peacetime population
is different from the optimum mix for our predicted
wartime patient load. This fact has not escaped the
budget analysts, who persist in suggesting that the
mismatch of peacetime specialties and wartime re-
quirements demonstrates that we are unable to fulfill
our primary mission with the physician assets we have.
U.S. Navy Medicine
SAC panel discussion: RADM R.G. Williams, Jr.; VADM W.P. Arentzen; RADM Stephen Barchet
They then argue that, since those assets would not
meet wartime requirements, we should not maintain
them in peacetime.
Our only defense is to show that physicians practic-
ing in one specialty in peacetime can fulfill another
function in wartime — that, for instance, a peacetime
specialist in OB-GYN could do general surgery in a fleet
hospital in wartime. Our training programs must assure
that kind of cross-specialization if they are to survive
the budgeting cycle.
The equivalent of the total personnel assets of the
Medical Department might be required for in-theater
support of a major war. The training programs we sup-
port must assure that our people are ready to deploy,
and that they have the skills they will need to do so.
Given the intense scrutiny that every item in the
DOD budget now receives from Congress, the Execu-
tive Branch outside DOD, and within DOD itself, there
can be only one interpretation of our circumstances:
Unless the Navy Medical Department can show that its
services are available and ready to fulfill its primary
mission, and unless it can show that its programs of
training support that readiness, it cannot hope for sup-
port in the budgeting process. In short, our survival
depends on our ability to convince the Chief of Naval
Operations, the Commandant of the Marine Corps, and
their civilian superiors that we are able and ready to
carry out our mission. The only arguments we can make
that will carry any conviction are to respond promptly
and fully to operational requirements, and to propose
programs to relieve inadequacies in our ability to
support those requirements.
It may lend a note of urgency to the problem for you
to remember that the Secretary of the Navy testified
before the President's Commission on Pay and Benefits
to the effect that it was not necessary for the Navy to
maintain a large peacetime Medical Department. We
have, since then, prepared a briefing for him which
succeeded in convincing him to alter his opinion. The
fact remains, however, that we are viewed in many
quarters as expensive, cumbersome, and dispensable
in favor of civilian sector care.
All of which brings us to the question, How should
contingency planning influence selections for specialty
Let me say first that we cannot compromise the quali-
ty of our health care system in any way. Those selected
for advanced training in our system must be highly
qualified academically, and of unimpeachable charac-
But let me add that we cannot compromise our mis-
sion through failure to consider it in the selection
Volume 69, November 1978
process. We must have training programs which pre-
pare our students for their contingency, as well as their
peacetime, roles. And we must have students in those
programs who recognize that their responsibilities as
naval officers stretch beyond the medical centers, and
who are willing to fulfill those responsibilities when
required to do so.
Today we have one surgical team and a two-physician
augmentation unit at sea with the Marine Corps, in
addition to the physicians, nurses, Medical Service
Corps officers, and corpsmen normally assigned to
those Marine Corps units. We have a medical care sys-
tem, reaching from Yokosuka to Naples, which may be
called upon tomorrow to support contingencies ranging
from natural disasters to full-scale war.
The specialty training programs which cannot be
identified with some aspect of contingency support,
whether directly or through additional cross-specialty
training, are in a most precarious situation. Likewise,
the Medical Department cannot afford to train, or to re-
tain on active duty, anyone who will not recognize his
responsibilities and willingly fulfill them.
It is not enough, however, to select the right people
for the job. Our training programs, as I have said, must
be adequate to prepare our students to fulfill the con-
tingency mission of the Medical Department as well as
to serve our peacetime patients. Part of the task you
assume here must be to define what additional training
would be necessary to permit practitioners of each spe-
cialty to serve effectively in a combat theater.
The specialty mix required for treatment of combat
theater casualties is, as you would expect, heavily sur-
gical. The requirements for anesthesiologists and for
surgeons in all specialties far exceed our peacetime as-
sets. The questions you must address are these: What
role would a specialist in my field play in field service
with the Marine Corps? with the fleet? in a definitive-
care facility in a combat theater? And, most important,
how can the operational versatility of such a specialist
be strengthened by emphasizing segments of specialty
training, or by adding to if?
Let me close with a plea that you undertake the edu-
cation of our younger physicians and of all members of
the Medical Department team. As outstanding medical
specialists, you enjoy the professional respect and
admiration of all your colleagues and subordinates.
They are, to a great extent, guided by your example.
Insofar as you show them that the Medical Department
must be committed to its primary mission, they will
make it so.
Yet it is all too easy to become immersed in the job at
hand and come to see the Navy as an adjunct to our
hospitals, rather than vice versa. It is our responsibility
to see to it that those we train remember those we are
here to serve.
The peacetime posture and attitude of the Medical
Department are made manifest to the operating forces
through the people we assign to duty with them, and
through the personnel of the surgical teams we deploy
with them. As we all know, however, duty with the
operating forces or deployment with surgical teams is
frequently viewed with distaste by junior and senior
members of the Medical Department and is either
actively avoided or accepted with bad grace. We also
know the reason for this: The duty is often boring. Few
patients, if any, require more than routine treatment,
and we are constantly aware that the work is piling up
for us, awaiting our return. And duty with organic
Marine assets can be uncomfortable as well as boring.
The point we must remember, and must drive home
to those we train, is this: The operating forces are not
conducting exercises for the fun of it. They are not, to
use a phrase too often heard from physicians, wasting
our time playing games. They are exercising so as to be
ready to perform their mission, and they have a right to
I need not harangue you on this subject, because you
know these realities already. I must urge you, however,
to bring those you train to share your realization. If they
do not, they will alienate our natural allies in the line
and Marine Corps and, in so doing, seal the fate of the
It has not been my intention to convey an overly
alarming or melodramatic impression of where we are
and what we must do; nor do I suggest any slackening
of our efforts to provide superb medical care to our
peacetime patients. Rather, I suggest that a full recog-
nition of our potential wartime responsibilities is the
best guarantee of our continued ability to provide the
best of health care to all our patients.
Medical Readiness for Opera-
RADM H.A. Sparks, MC, USN
Deputy Surgeon General and
Assistant Chief for Headquarters Operation
At the outset of my remarks, may I offer one simple
observation: that is, that each and every one here today
has a very special involvement in the status and effec-
tiveness of our Medical Department's operational med-
That is why we are here! It is our primary responsi-
bility to conserve the military manpower of the Navy
and Marine Corps. In peacetime we must maintain the
health status of our forces through health education,
U.S. Navy Medicine
health protection, and personal health care, all of which
has but one goal: readiness. Simultaneously, the Medi-
cal Department itself must be ready to make a prompt
transition from its peacetime posture to a well-trained,
properly outfitted, and carefully positioned worldwide
Medical Department force.
We are an integral part of the naval warfare system
of our nation. Our contribution to the nation's defense
is to provide medical support to those naval forces
whose mission is to control the sea lanes and to project
Where did we come from? We were born of the line.
Our birth as an organization came from recognition by
the line that our skills were desirable and needed— and,
indeed, medical personnel first appeared on board
Today we have some 728,000 Navy and Marine Corps
men and women in uniform. We have an additional
136,000 direct-hire civilians working in such facilities as
naval shipyards, ordnance plants, and naval air and
Our Surgeon General has set as our first priority the
health care support of the operating forces. Our second
priority is occupational and industrial health services to
our civilian workers. Thus, we have medical responsi-
bility for at least 860,000 people in our two top priority
Another factor that must be considered is the stra-
tegic deployment of our naval and Marine forces over
the entire surface of the globe. Although our logistic
capabilities have increased, through the marvels of
technology, so that we can move men, materials, medi-
cal facilities, and the like with relative ease, we often
find ourselves engaged in new and hostile environ-
ments. The Medical Department of today's Navy must
be prepared for contingencies in every area of the
world, under any circumstance.
It is extremely important for us to understand the
concept of a worldwide contingency health care system,
for the resources to support it are being justified by
carefully articulating such a concept, including the
education requirement — which, of course, is why we
are here today.
One hundred years ago, when the fleet began con-
verting to steam boilers, great concern was expressed
by fleet surgeons over problems created by stifling
heat. Early changes in structural design, engineering
changes, and limited watches for personnel were
accomplished because of the concerned action of medi-
I can assure you that we still have those very same
concerns today. And to that list of circumstances that
impact on our operating forces, we can add such items
as noise, asbestos, toxic paints and chemicals, ionizing
and nonionizing radiation, lasers, and physical and
psychological stress caused by such things as G-factors
or prolonged duty under the polar icecap, just to name a
Not only must we keep in touch with the latest de-
velopments in the medical /scientific community, but
we must also keep abreast of the technological develop-
ment of the Navy itself. We must be fully aware of both
and be able to match both at any given point in time.
Perhaps the most awesome circumstance today is the
technology of war itself, and the possible adversary we
would face in such an event. There can be no doubt that
the ultimate aim of communism remains the domina-
tion of the world and the elimination of the free-world
democracies. There is also no doubt that the quickest,
surest way of achieving this would be military victory
over the West, if we were to relax our vigilance and
strength. To this end, both sides have built up the
greatest and most terrible array of military weapons
Since World War II, the Soviet Navy has been trans-
formed from a basically coastal defense force into an
open-ocean force, capable of carrying out general pur-
pose naval missions supporting Soviet global political
and military objectives. As of 1 July 1977, the Soviet
fleet comprised approximately 2,875 ships. In numbers
alone, that represents a fleet more than six times the
size of ours.
There's no disagreement that a major war between
the United States and the Soviet Union would be devas-
tating to both sides and of relatively short duration.
Quick-strike capabilities can bring the destruction of a
nuclear attack to our land-based activities within a
matter of hours. Fifty-five important U.S. cities, with
Volume 69, November 1978
some 71 million people, are located within 530 miles of
the 100-fathom-depth curves of both the Atlantic and
the Pacific Oceans. Civilian and military casualties
would run into the millions. Our major cities would be
leveled, and our way of living, as we know it today,
utterly destroyed. The responsive ability of the survi-
vors would depend solely on offensive, retaliatory,
mobile naval forces.
Let me compare the suddenness and short duration
of such a war with what happened to us in World War
II. After the attack on Pearl Harbor, we fought what
amounted to a holding and delaying tactic until produc-
tion and manpower reserves of the country were geared
up to meet and defeat the enemy. At the same time, our
medical people were learning as they went along.
Some say that combat medicine is not something that
you can really get prepared for — that you only learn
under combat conditions. Well, we'd better reject that
notion, because I can tell you we won't have the time to
learn as we go along.
In the Navy Medical Department, every uniformed
man and woman must be ready within hours to take up
his or her position in support of the operational forces of
the Navy and Marine Corps. Each one of us had better
know what we are doing under every conceivable cir-
The degree of readiness we attain during peacetime
and our response time to varying levels of contingencies
are the true measures of our competence as Navy medi-
What, then, should be the posture of the Medical
Department today with regard to operational medicine?
The choice is not really ours; it has already been
made for us by those in authority to make such choices.
I've already told you of the priorities set by the Surgeon
General. These priorities are established by the Chief
of Naval Operations. Jointly, their objectives are to
"give the highest priority to health care support of the
operational forces" by providing "full preventive and
curative medical and dental services to active-duty
The reality of our commitment to the operational
mission can be found in the CNO's budget, which gives
us our financial life's blood. Each and every billet in
that budget is supported by its contingency require-
ment in support of the operational forces in case of
mobilization. In plainer words, the only justification for
any man or woman to be in the uniform of the Medical
Department in peacetime is based totally on a projected
In our considerations of how we make ourselves
operationally ready, there are two areas that deserve
our special attention.
First, all members of the Navy Medical Corps must
recognize and appreciate their dual roles as military
medical specialists and as clinical specialists. We are
not structured for personnel who see the Navy Medical
Department as just another place to practice clinical
medicine in the traditional sense. The acceptance of
this dual responsibility cannot consist only of a tacit
cerebral acknowledgment that, in case of war, "I will
go forth and do my duty." Acceptance means we must
be ready to assume those duties, and readiness re-
quires us to be willing to devote a portion of our time on
assignment with the operational forces either afloat or
in the field. Any member of the Medical Corps who
cannot accept the dual military-clinical role that sets
him apart from his civilian counterpart has no business
in the service. He or she should seek employment else-
Second, all medical education programs and work
experiences must address themselves to the readiness
preparation of Medical Corps personnel. The training
education experience in peacetime must prepare us for
all manner of circumstances, environments, and con-
By this I mean to emphasize that the training inter-
face between clinical and operational medicine must be
so close that no boundary can be discerned. To suggest
that the two should not be mutually complementary is
to deny reality. However, I must acknowledge that our
current training programs are just not adequate to meet
all fleet operational needs.
To remedy that deficiency, an operational medicine
BUMED-HSETC training seminar-workshop was con-
vened in San Diego on 12 June 1978, at the direction of
the Surgeon General. The assigned tasks of that as-
semblage were to:
• Review and inventory present operational medi-
cine practices in their relation to training programs and
• Identify specific knowledge and skill deficiencies,
and recommend steps to overcome them.
• Recommend a general system of operational medi-
• Recommend career pathways of training and de-
velopment in operational medicine.
• Construct initial curriculum outlines for selected
operational training programs.
I am pleased to report to you that all of the above
tasks assigned to the workshop were accomplished.
With respect to Medical Corps officers, the following
recommendations were set forth:
• All medical officers entering active duty will attend
30 days (81 hours) of military indoctrination at Newport,
• Medical officers who have not done so will com-
plete the GME-1 year.
• Medical officers may complete additional GME
training in selected cases.
U.S. Navy Medicine
• Medical officers who may have completed all post-
graduate training may be assigned to NRMCs or go
directly to the Operational Medicine Common Core
Training Course. Such schools are to be established in
San Diego and Norfolk. The course curriculum will re-
quire 161 hours of study, and features occupational,
industrial, and preventive medicine. All medical offi-
cers assigned to operating forces will attend and then
proceed to additional operational training at the field,
surface, flight, or undersea medicine training facilities,
or to an operational tour in research facilities.
■ • Upon completion of the first operational tour, the
medical officer may select additional professional train-
ing in residency, fellowship, or advanced degree pro-
grams. Some candidates may be selected for advanced
special service schools.
I believe that the implementation of this task-ori-
ented program will provide a cadre of 3,650 physicians
who can serve with great satisfaction as qualified mili-
In summary, may I say that we must never lose sight
of the job we have to do, and we must do that job with
Medical Department Personnel:
Issues and Initiatives
RADM R.F. Milnes, MC, USN
Assistant Chief for Human Resources and
BUMED Code 3
This is a time for me to consider your ideas, your con-
cepts, and your plans— and a time for you to know what
we are thinking and doing to provide you with the tools
to give our patients the kind of medical care we know
I have come to Code 3 with a positive spirit. I accept
the concept that we are managing in an era of constant
change, and that it is mandatory to accept this pace,
which is fast, uneven, and certainly complex. It is also
important to approach our tasks with the view that we
can effect some positive results right now — and with
the aim to do more in ensuing years. I can assure you
that my staff and I believe we can.
Our assets are our people, our product, and our ac-
complishments. Our problems, simply stated, are ac-
cession, retention, and attrition. But manpower is
people, not hardware. If hardware doesn't work, it
breaks— and people react if things aren't right.
Realizing this, I pledge my office to do what it can to
provide people with the opportunity to grow and attain
a quality of professional life that they seek.
My goal is to provide full support for operational
commitments and equally strong support for our train-
ing programs. The success of this dual support is vital
for our future and our viability as a Medical Depart-
I intend to create a sense of integrity in our inter-
actions with you. It is necessary for all of us to com-
municate. Our effectiveness requires your help and
I view one general problem, in particular, with con-
cern, and I solicit your support. I would ask all of you in
positions of leadership to embrace wholeheartedly our
efforts to demonstrate that operational tours are valu-
able—that such a tour is a positive challenge to anyone
who has chosen to become a part of the Navy, and that
this arena is one where much can be accomplished.
Our operationally deployed GME officers will do
much to lend credence to our efforts and help solve this
highly visible problem. However, we need to work to-
gether to turn this around to our advantage. This is
crucial for our service integrity.
Next year, we will place 280 primary care medical of-
ficers in operational billets. That number is our commit-
ment to the operation of the fleet and to the Marine
We do have some very positive aspects of our in-
ventory. This year, 557 scholarship students have
joined us, and not all of these students are entering at
the first-year level. This certainly gives the coming
years a much healthier look than we have been expe-
riencing. These students are of high quality and come
from well over 1,000 applicants— they really look good.
Family practice programs are delivering family prac-
tice specialists in increasing numbers. These physi-
cians are in demand, and we are detailing them to more
diverse locations, where they have been welcomed with
open arms by our consumers.
The Physician's Assistant Program starts again in
1979, with an expected increased output of these
valuable extenders, who will be able to help us not only
in our clinics but also in certain operational areas that
can utilize their expertise. We have already chosen a
physician's assistant consultant, who will be stationed
at the hospital in Charleston but will be responsive to
all physician's assistants. He will provide an important
interface with us at BUMED and lend a great deal of
stability to the physician's assistant community.
The Nurse Corps has gained billets, and the people to
go with them will increase the overall nursing com-
munity to help cope with the increasing demands made
on nurses by new JCAH directives. These directives
will require your attention, as they call for significant
changes in nursing assessment and care plans. For
Volume 69, November 1978
example, a patient classification system will be imple-
mented in our hospitals, in order to determine patient
needs for nursing care, and the long-range and daily
nurse staffing requirements within the hospitals.
Physician recruiting has changed little from last year,
numberwise. But quality has improved a great deal,
and American-trained physicians are more numerous,
even if on a small scale. We expect to recruit close to
200 medical officers this year.
Last year, 55% of those recruited were FMGs, and
45% were American trained. This year these percent-
ages are reversed, and those FMGs who apply are more
apt to have their citizenship. We like this trend, and
you can affect it significantly by being responsive to
your area recruiters.
The Variable Incentive Pay Program has been ex-
tended two years, and a new bill has come along to in-
crease professional pay and eliminate some of the
inequities and vexations of the present system. Also,
there are strong indications that a pay initiative will be
promoted for our enlisted personnel this next year.
The lack of ancillary help which all hospitals have
experienced, and which is the source of adverse com-
ments from our physicians, is getting attention. One
hundred forty-four additional ceiling points have been
added to our inventory in this problem area; however,
recent events indicate that Congress once again intends
to seek increased decrements in our civilian inventory.
We have not solved this problem, but we are working
Our major concern this year has been the loss of criti-
cal specialists. We are short in areas all too familiar to
you: orthopedics, radiology, psychiatry, OB-GYN, and
surgery. We don't have an immediate fix, but we do
know there is something that will help, and that comes
under the heading of personnel counseling. This needs
your utmost attention, as it can limit attrition and in-
crease retention. The devoted interest of a commanding
officer, a director of clinical services, or a department
chairman in the younger staff is, without question,
where retention efforts are most effective.
When you can honestly project your positive spirit
about Navy medicine, it is productive. I don't feel in
any way that this request is passe, because it is one of
the more commonly stated reasons physicians give
when they leave the Navy.
Your efforts to retain our corpsmen are invariably
worthwhile. Please take the time to talk with them and
help them plan a future.
The decreased opportunity for promotion has been a
negative factor in its effects on attrition and retention.
This year, for Medical Corps officers, there will be a
90% opportunity to be selected as commander, instead
of the 80% of last year. I am pleased that this has been
turned around, and that we will be able to extend the
opportunity to attend executive medicine courses to
selected lieutenant commanders in the Medical Corps.
The situation with regard to corpsmen is receiving a
great deal of study and attention. For example, the
Navy Occupational Task Analysis Program (NOTAP) is
a study coming to fruition in the spring. This very de-
tailed and extensive computerized evaluation of jobs
filled by our corpspeople will let us upgrade occupa-
tional standards, help us learn about job satisfaction,
and allow us to compare jobs for commonality or dis-
tinctiveness. It will help us utilize our corpsmen better,
which unquestionably we need to do. We also can, with
hard data, pursue our requirements more effectively
with those who control the budget and distribution of
We need new programs to assist our E-8 and E-9
community in gaining increased supervisory manage-
ment skills. These are being developed and can signifi-
cantly enhance the value of senior enlisted staff in all
segments of the Medical Department. I strongly en-
dorse greater involvement and utilization of the master
chiefs and senior chiefs of our commands, and I urge
you to do this also. They are in a position to unite a com-
mand and help you obtain the optimum from Hospital
In recent years, we have never been fully able to
compete for manpower in Congress. Now we have the
oncoming data from SHORSTAMPS, our Shore Re-
quirements, Standards, and Manpower Planning
System. The facts generated by this study give us a
defensible manpower planning system which, when
presented to Congress, will substantiate manpower
needs and our budget requirements.
So far, only a small segment of medical activities has
been analyzed. Orthopedics is one specialty whose
study has been completed. It clearly demonstrated a
requirement for more orthopedic surgeons than are
presently authorized. We have, I believe, all known this
to be true, but in the past we have not been able to
quantify our needs to satisfy the statisticians.
The SHORSTAMPS methodology has been advanta-
geous to other branches of the Navy and also to the Air
Force. We believe it will help us also.
Finally, you need to know that we have factor-coded a
number of our billets. Functional area coding was
always a mystery to me, and I suspect also to you.
Actually, these codes are used to identify billets that
require special consideration or are not within stated
In essence, functional area coding will help us alle-
viate our billet requirements. For example, 178 Medical
Corps billets have been temporarily released to
increase our numbers of nurse and Medical Service
Corps specialists, such as dietitians, clinical psycholo-
gists, and nurse anesthetists.
U.S. Navy Medicine
We have FAC-coded 104 billets which support the
operational units of the Marine Corps. These people are
medical specialists who will remain at their assigned
hospitals but will be required to have initial field
medical training and yearly short periods of field up-
dating. It is a viable solution to 100% manning of es-
sential operational requirements. Our specialists will
be able to work in their field of expertise, but will also
be properly oriented to a role in contingency planning.
Medical Corps Manpower
CAPTJ.E. Carr, MC, USN
Director, Medical Corps Division
BUMED Code 31
It has become a tradition in the Medical Corps Divi-
sion that this SAC meeting marks the commencement
of our detailing year. It's appropriate that we take this
time to evaluate what we have accomplished, where we
are today, and what our goals will be for the future.
As VADM Arentzen and RADM Milnes have men-
tioned, we are in a much better position now than we
had anticipated at SAC IX, as the tables that accom-
pany this presentation will confirm.
Table 1 is a historical comparison of our authorized
billets and our onboard strength. It demonstrates that
since 1969 our billets have decreased from 4,404 to the
present level of 3,636. Our onboard strength has con-
tinued to fall, and we will be approximately 167 physi-
cians below authorized billets on 1 Oct 1978. Last year,
at SAC IX, we predicted that we would have a deficit
between 250 and 450 physicians this year. We reached
a shortage of 242 physicians in May 1978, and then our
position improved. This was caused in part by an in-
crease in extension on active duty requests and a level-
ing off in retirements and resignations.
Table 2 is a graphic demonstration of the authorized
billets and onboard strengths as demonstrated in Table
1. It shows that our Medical Corps inventory has now
reached a plateau, as predicted, and it is projected that
we will continue to improve until we reach our Medical
Corps requirements. My prediction now, at SAC X, is
that our shortage of physicians should not be much
worse in October 1979 than it is today, and hopefully
will be somewhat better. As we enter the 1980s, we
should be able to reach end-strength.
A comparison of the physician shortages in the three
uniformed services in shown in Table 3. The Army is
experiencing a deficit of approximately 1,500 medical
officers, and the Air Force has a shortage double that of
The Medical Corps grade distribution is presented in
Table 4. The line Navy perceives that we are top-heavy
in the grades of captain and commander, and it was this
perception that influenced our promotion policies in
recent years. Fortunately, Navy line leaders are under-
standing our position, and we are now seeing a reversal
of our present restrictive promotion policies and, hope-
fully, a full return to a liberal promotion policy.
Table 5 shows the number and grade distribution of
female medical officers on active duty. We now have
193 female physicians, representing about 5% of our
strength. This level should steadily increase over the
next decade, and this is causing a reexamination, in
depth, of all the roles held by women in the military.
We expect to assign our first female physicians to at
least five ships, starting in July 1979.
We've been telling you for several years now that the
Berry Plan is coming to an end. Table 6 shows that we
accessed some 32 Berry Plan physicians this summer
and will be looking for the last 9 during July 1979. The
loss of this pool of specialists — which accessed some
750 physicians each year, and which provided us with
approximately 1,500 on duty at any one time— will be
Table 7 is a display of the specialty shortages, com-
paring physician requirements with actual inventory.
This is what you and your commanding officers tell
BUMED that you need to carry out your mission. From
this it is evident that we have a relative shortage in
almost all specialties. But there is a problem with this.
TABLE 1: Medical Corps Worldwide
End Fiscal Year
'Source: OPNAV 104
"Source: BUMED Code 31. Reflects end-strengths.
Volume 69, November 1978
TABLE 2: Actual and Projected Medical Corps End-Strengths
USN PEACETIME MEDICAL CORPS REQUIREiCUi:
3467 USN MEDICAL CORPS INVENTORY (bodies)
TABLE 3: Physician Shortage, 1 0ct 1978
TABLE 4: Medical Corps Grade Distribution"
'Data as of 1 Oct 1978
Source: BUMED Code 31
U.S. Navy Medicine
TABLE 5: Medical Corps Grade
TABLE 6: Berry Ran Accessions
Oct 78 (FY-79)
Oct 79 <Fr%80)
TABLE 7: Specialty Shortages (Requirement/Physicians) 1 Oct 1978
Preventive Med (Gen)
Preventive Med (Aero)
Preventive Med (Occup)
Volume 69, November 1978
_E 8: Selected Medical Officer Inventories, 1 Oct 1978
Surgery — Neuro
Surgery — Orthopedics
* Inventory does not reflect specialties assigned to executive medicine (99) or medical research (47), and
total does not include medical officers
in residency training.
** Requirements defined by authorized specialty billets.
'"Shortages defined by billet authorizations.
TABLE 9: Desired Primary Care Specialists
TABLE 10: Primary Care Specialists
156 - 29
Clinical specialty subtotal
124 - 17
Clinical specialty subtotals
619 + 8
Military specialty subtotal
184 - 36
40 - 8
Military medicine subtotals
224 — 44
475 + 64
699 + 20
1318 + 28
U.S. Navy Medicin
TABLE 11: Physician Recruitment'
*As of 6 Sept 1978
TABLE 12: Specialties of Physicians Recruited
TABLE 13: Specialties of Physicians Recruited
99 = 176
*As of 6 Sept 1978
73 = 159
Table 8 compares our physician inventory, not with
need or requirement, but with authorized billets. In this
display, our shortage is not so apparent, and it would
appear that we have a deficit in only several specialties.
This is our daily problem: to document what our re-
quirement actually is. Stated simply, we do not have
enough billets to take care of our entire beneficiary
Table 9 is a presentation of our desired primary care
requirements. We would like to attain a goal of 47% of
the Medical Corps in those primary care specialties.
Family practice should double over the next 5-10 years.
Table 10 is a display of our actual inventory of pri-
mary care specialists. They are now at 38% of the
Medical Corps, an increase from 35.6% last year.
Physician recruitment over the last four years is dis-
Volume 69, November 1978
TABLE 14: Armed Forces Health Professions Scholarship Program
TABLE 15: PCMOs (GMOs) Needed for
Operational Billets (Summer 1979)
TABLE 16: PCMO Assets to Fill Operational
Billets (Summer 1979)
Marines, Seabees, Regions
played in Table 11. Recruiting for FY-78 will be about
the same as for FY-77, and we now are able to access
some commanders in certain critical specialties.
Table 12 is a final report for recruiting last year (FY-
77) and shows that foreign medical graduates exceeded
U.S. -trained graduates during that year. This trend has
now been reversed, as you will note in Table 13.
The Armed Forces Health Professions Scholarship
Program is displayed in Table 14. We were able to
select some 557 students from more than 1,000 appli-
cants, and our program is fully subscribed. This will in-
crease the number of graduates available to us. We
have increased the number of Navy internships and
hope to increase civilian deferments in the future. This
expanding pool of scholarship students— which, to-
gether with graduates of the Uniformed Services
University of the Health Sciences, will provide us with
approximately 1,500 physicians on active duty at any
one time— is our hope for the future. We will need to
train them in order to provide our specialists of the
For four years now, we have promised the line Navy
that we would support the fleet with 100% physician
manning. We have done a pretty good job, and we
intend to carry out that promise again next summer.
Table 15 shows that we will need 280 primary care med-
ical officers to replace those vacating operational billets
next summer. Table 16 shows where our assets are to
come from to fill those operational billets, and you can
see that the margin is very narrow.
Please forgive me if I appear to be overly optimistic.
But we have been through, and are going through, a
very difficult time, and yet the signs are improving. The
quantity and quality of scholarship students is marked-
ly increased. Extensions are ahead of last year's num-
bers. Recruiting is holding its own, and the quality of
recruits is decidedly better.
Again it has been confirmed that we cannot depend
upon recruitment to supply us with trained specialists.
We must continue to try to train at full capacity, while
supporting the operational Navy to the best of our
U.S. Navy Medicine
Budget Update: Dollars,
RADM A.C. Wilson, MC, USN
Assistant Chief for Materiel Resources
BUMED Code 4
This morning I want to address the current status and
outlook on the Medical Department's money, places,
and things. Since money is critical to virtually every-
thing, I will start with the status of funding, then de-
scribe for you the facilities and equipment milieu.
In retrospect, we have not fared too badly in FY-78,
although we've had some anxious moments at various
times, wondering whether or not this or that piece of
the budget would be approved or withheld.
The Navy Medical Department is a microcosm of the
government as a whole, in the sense that it responds to
the various pressures brought on by changes in this
country and the world in general. The circumstances
which are now influencing our budgetary matters are
several— for example, the Presidential pledge of a
balanced budget, which means either higher taxes or
lower government costs. Proposition 13 in California
has had an enormous impact and has been the driving
force in reduction of government spending.
In the Medical Department we have experienced a
consistent decline in workload, due in part to reduction
of the end-strength of the Navy and Marine Corps and
in part to reduction in the average length of patient stay
in the hospital. Yet, when the length of patient stay is
reduced, the cost per patient day rises, because the cost
of keeping the door open either remains stable or rises.
In 1976, there was a $10 million reduction in BU-
MED's budget base. Since the budget is constructed on
an incremental basis— i.e., next year's budget is
usually this year's budget plus some new programs
plus inflation— the base on which the next budget is
calculated is critical. To date we have been unable to
get the budget base restored to the figure that it would
have been prior to 1976, using a 1975 base. That's been
As a part of the Navy, we have received our fair share
of general forms of reduction. Over the past few years,
these have included dollar reductions; staffing reduc-
tions, both in uniformed personnel and civil servants;
constraints on travel funds; reduction in dollars to deal
with inflation; and limitations on the growth of some
desirable programs, such as OSHA.
As you are well aware, the history of low funding has
created some retention problems. We are, by law and
custom, expected to deliver health care on request. Any
reduction in care, whether real or imaginary, is per-
Volume 69, November 1978
FIGURE 1 : Major Budget Changes for FY 1979
(as Requested in FY 1979 President's Budget)
General Support Staffing (270 civilians)
Occupational Health (80 technicians)
Safety (14 safety officers)
Hearing Conservation (16 technicians)
Maintenance and Repair —Real Property
Minor Construction /Alteration
Laboratory Technicians (38 civilians)
Total — Major increases
FIGURE 2: FY 1980 Budget (Currently Undergoing
Occupational Health (Contracts)
Maintenance and Repair— Real Property
Closure of Inpatient Functions at
ceived as a condition which is reversible if one com-
plains loudly enough.
There is another issue impacting on us, and that is
doing as much as possible by contract.
If we contract for a service, it obviously means that
we do not require a Civil Service employee or a uni-
formed individual to do the job. This impacts on the
Civil Service end-strength of the Medical Department,
and can impact on our uniformed strength as well.
Certain functions in selected activities lend them-
selves to contracting out— for example, housekeeping
and food services. But those skills which we are re-
quired to take with us when we go to war— the skills of
men and women in uniform— must continue to be exer-
cised. Our efforts are devoted to determining where
and what we should contract out, and what skills we
must protect as the necessary ones for contingencies.
The bottom line for all these issues is that we are
being asked to do more with less. We try to cut corners
to save dollars, but there are pressures beyond our
control which do not permit our independence in these
matters. As a result, we find ourselves in a "reaction"
posture rather than in an "action" posture. We are
sometimes asked to refight battles we thought we'd
Figure 1 shows the major budget changes in FY-79.
There's a strong emphasis on occupational health,
maintenance, minor construction, and addressing the
We're getting dollars for FY-79, but as of today we
do not have a firm control number that tells us what our
dollar figure will be. We do know that we have had our
inflation line item decreased by about one third, but the
other decisions haven't been announced. The general
feeling about FY-79 is that it may not be a vintage year,
but it may not be all that bad, either.
Figure 2 outlines the major changes we've asked for
in the 1980 budget, which is currently undergoing re-
view by Navy, OSD, and OMB.
In the upcoming year, the Medical Department needs
the conscious efforts of all its members to assure that
we spend our money wisely and well and get the
maximum benefit from it. These are some of the things
you can do to contribute to sound financial manage-
• Get involved and stay involved. As program man-
agers, you know there's nothing in this country that
changes as rapidly as the price of things. To manage
your money adequately, you must know not only what
you have and what it costs to operate and maintain, but
also what you want to replace and what it costs to buy
• Being a target manager or a program manager
does not mean only spending money. There's a require-
ment to manage those dollars: to identify alternatives
and options, and to spend those dollars on the best
options. If you've had no experience or are having trou-
ble managing your department's budget, the fiscal or
supply officer would be happy to give you a hand and
help you learn.
• You must stay current, for the reasons we've just
mentioned. The marketplace changes daily, and what
you determined was a sound operating cost or replace-
ment cost last week is likely to be out of date this week.
• You must learn to forecast — to look ahead and
identify problems before they occur— so we can plan for
that new piece of equipment you need to stay abreast of
the state-of-the-art of medicine. Problems and require-
ments need to be identified early.
• Finally, you must plan ahead. As you know, the
Navy and the government at large operate on a
five-year defense plan. We need similar plans for the
Medical Department and its activities, and this includes
your department. You need to think about and discuss
what things are probably going to transpire in the next
five to ten years. Will the anticipated changes in the
state-of-the-art affect your specialty? Will those
changes require more people, more money, more
space, or additional equipment? If they do, how much,
and what kind of each will be required?
In 1974, we started a medical modernization program
for our facilities, designed to remedy construction
needs over a five-year period. The money for this pro-
U.S. Navy Medicine
gram was held under tight control by DOD, through a
mechanism known as "fencing," for the first three
program years. In FY-77, however, the money was un-
fenced, and control was returned to the individual mili-
We've accomplished an enormous amount of con-
struction since 1974: 68 major projects were authorized,
and 13 are still under way. In FY-79, we have six proj-
ects: a new hospital at Camp Lejeune, a new regional
dental center at Norfolk, the third phase of center re-
development at Bethesda, replacement of the biomedi-
cal research laboratory in Cairo, an industrial clinic at
MCAS Cherry Point, and a medical/dental clinic for the
basic school at Quantico.
We still have $900 million worth of construction to
accomplish; however, in FY-78 the Medical Depart-
ment construction program was all but eradicated. We
built one BEQ in FY-78.
FY-79 looks better, with a pricetag of about $71 mil-
lion on those projects I mentioned.
One point should be remembered: All the work in the
Navy Medical Department is important work or we
wouldn't be doing it. but every program we present is
in competition with ships, aircraft, weapons systems,
and other Navy programs. There's a strong feeling in
government today that we must do everything possible
to maintain what we have, at the same time competing
appropriately for new things. In the facilities world, this
means more emphasis on maintenance and repair of
existing systems and spaces, and it means that you
must be continually aware of the maintenance needs in
your own areas of responsibility.
Just for a moment, I'd like to highlight some of the
things that are now going on.
We returned some property to the Japanese govern-
ment, on a quid pro quo basis, and they're building a
new hospital for us in Yokosuka that should be ready for
us to use in about a year.
The new hospital at Bethesda is about 18 months
from completion, and construction is going along very
nicely. The last phase of the total NNMC project-
modernizing the tower and other older buildings— is
programmed in FY-81.
As many of you know, weve had considerable diffi-
culty siting the San Diego replacement hospital, but
we hope the issue of the new location will be resolved
shortly, so we can get the new hospital built.
We're starting a tri-service study of medical care
needs in the Oakland Bay area, the driving force behind
which is the fact that, as new as Letterman and Oak
Knoll are, they've not designed to withstand earth-
quakes. Both of them need seismic upgrading, which is
very expensive, and that's the reason for this study: to
determine if we need both hospitals and, if not, which
one should close? We're well aware of the large con-
tribution Oak Knoll makes to our total training effort.
Suffice it to say that no decisions have been made
ahead of time, no commitments have been made, and
the study will be objective.
As you know, the New Orleans hospital is finally
closed. We don't know what's going to happen to it, but
it's being offered for lease.
The final issue I'd like to discuss is our equipment
The Equipment and Logistics Division, BUMED
Code 43, was established a year ago, with CAPT Lou
Mantel as its director. We now have a much better
management system for our equipment than we had
before. We've had good support from CNO in FY-78 in
getting equipment dollars. FY-79 doesn't look quite as
favorable, but we're still far better off than in many
years in the past.
You're undoubtedly well aware that the computer
tomography scanner has brought a new kind of surveil-
lance to the equipment program. Virtually every
governing body in the country, from OSD down to the
local community health planners, is interested in con-
trolling the number of CT scanners. We're doing rea-
sonably well in our own program.
We're planning new equipment-related programs
for the upcoming year, the most important of which
is better preventive maintenance. LT Tom Defibaugh
has been transferred to BUMED Code 43 from Phila-
delphia's Naval Medical Materiel Support Command,
and he'll be setting up the maintenance program.
We also anticipate moving the Naval Medical
Materiel Support Command to Fort Detrick. The Army
and Air Force have their medical materiel divisions
there, and the move will allow us to take advantage of
the other services' systems and programs.
BUMED Code 42 will continue its usual function of
caring for the fleet, but in addition will start some new
activities, including an inventory control system for
investment equipment and some noninvestment equip-
ment. To sum up, we've talked about money and how
hard it is to come by. We have to use it wisely. We've
had pretty good luck this year, and we're hopeful about
We've said that the military construction program is
constrained in funding somewhat, but we're still build-
ing some new facilities, and we're making some pro-
The equipment scene is improving. We're moderniz-
ing and enlarging the equipment acquisitions system in
BUMED, and putting emphasis on proper selection,
proper utilization, and proper maintenance.
All these issues involve you as program directors,
and it is incumbent on you to contribute your time and
expertise when indicated, so that we can continue to
march along in the right direction.
Volume 69, November 1978
Your Reimbursements: Speeding the Process
If you are a student in the Armed
Forces Health Professions Scholar-
ship program (AFHPSP), you are
familiar with reimbursement
claims. They are a necessary evil,
requiring time to fill out and time to
process. They are completed on
Standard Form 1164 and are sub-
mitted once each Fiscal quarter.
Reimbursement claims take ap-
proximately four to six weeks to
process and are responsible for
about 40% of the workload at Code
9, Health Sciences Education and
Training Command (HSETC). This
is the process that your reimburse-
ment claim (along with 1,500 others
each quarter) must undergo before
payment can be made:
• About a month before the end
of each federal fiscal quarter, a
blank SF 1164, an instruction sheet,
a school certification, and an infor-
mation letter are mass-mailed to all
• You and other students in the
AFHPSP complete your claims for
the applicable fiscal quarter (termed
"purchase period" on the instruc-
tion sheet) and return them to Code
• When we receive your claim, it
is date-stamped, then screened for
signature, purchase dates, mixed
purchase periods, social security
number, and readable carbon cop-
ies. Claims are immediately re-
turned when there are discrepancies
in any of these areas.
• After your claim is screened,
the receipts are copied and passed
on to your processor. The processor
reviews your past claims, checks
your items against your receipts,
checks the addition, separates the
amounts into categories (books,
supplies, fees, microscope rental),
and enters the categorized amounts
on your personal record and in a
master financial book that main-
tains a running total of all money
expended on behalf of Navy
AFHPSP students. The processor
must then type accounting data and
signature information on your
claim. The first carbon copy and a
copy of all your receipts are filed in
your personal financial record while
the original claim, with remaining
copies and receipts, is forwarded to
the HSETC comptroller for further
review and signature.
• The HSETC comptroller's of-
fice screens your claim for account-
ing-data accuracy and sends one
carbon copy to the fiscal office at the
National Naval Medical Center for
keypunching. This is the copy that
charges the amount of your claim
against HSETC funds. The original
claim and the remaining copies are
then forwarded to the Navy Re-
gional Finance Center (NRFC) in
• NRFC processors review the
claim, check your receipts, check
the addition, and finally forward
your claim to their fiscal office for
payment. The fiscal office makes
out your check and forwards it to
you, using one of your claim copies
in a window envelope. The original
claim and remaining carbon copies
are used for other purposes within
As you can see, your claim passes
through many hands. There can be
a bottleneck at any point along its
journey when processors take leave,
report sick, spend too much time on
"problem" claims, or attend to
other more pressing matters that
divert them from their processing
Your help counts. You can help
speed the flow by submitting neat,
legible claims and closely following
the instructions that accompany
each claim form. Unfortunately,
many students do not read the in-
structions and are perturbed when
their claims are returned for seem-
ingly minor discrepancies. For a
time, these minor discrepancies
were simply corrected by the proc-
essors. As time passed, however,
more and more students were dis-
regarding the instructions, to the
point where almost every claim
needed some type of correction or
adjustment. It became apparent
that the only way to ensure that
claims were properly completed was
to return them to the student when-
ever there was a discrepancy.
One of the most frustrating prob-
lems encountered by NRFC is
carbon copies that cannot be read.
Every copy is used, and all must be
We do not like to return your
claim because of minor errors, but it
is the only way to ensure proper
submission in the future. Claims
processing is not a simple, one-
office procedure. Each office in the
processing chain must abide by
established laws and regulations.
That is why we are so particular
about receipts, dates, signatures,
legibility, content, and neatness.
We may not be able to change the
system, but with your help we may
be able to make it a little more re-
U.S. Navy Medicine
SURVEY TO DEVELOP PHYSICIAN WORK PROFILE
... In the latter part of this month and early in Decem-
ber, the Naval School of Health Sciences, Bethesda,
Md., will be conducting a survey of all shore-based
Past surveys, which have tended to focus on career
satisfiers and dissatisfiers, have too often resulted in
conclusions and recommendations that are not readily
subject to in-house control. The current survey, how-
ever, addresses the Navy physician's immediate job
environment. What does the physician do? Who sup-
ports him or her? How well is he or she supported?
What organizational factors enhance or inhibit the phy-
With an accurate physician work profile, Medical
Department managers can better modify organizational
arrangements so as to match physicians' professional
goals with the varied needs of their patients.
Since a survey investigation, by its very nature, re-
quires the whole-hearted cooperation of respondents to
be successful, the Research Department of the Nava!
School of Health Sciences earnestly solicits that coop-
eration from Navy physicians in the days ahead.
MED SCHOOL OPPORTUNITIES IMPROVED . . .
ROTC and service academy graduates can now partici-
pate in government medical education programs. The
three military services have moved to allow ROTC
graduates and as much as 2% of the graduating class of
each academy (depending upon service needs) to enter
the Armed Forces Health Professions Scholarship
Program or attend the Uniformed Services University
School of Medicine.
FLIGHT SURGEON BILLETS AVAILABLE . . . Billets
are available for flight surgeons at the Naval Aerospace
Medical Research Laboratory, Pensacola, Fla., and the
Naval Air Development Center (NADC), Warminster,
The NADC billet is described as follows: "A new
generation of Navy aircraft is capable of sustained
high-G flight. At NADC, research is directed toward
enhancing pilot performance for the demands of this
environment. There is an immediate requirement for an
experienced flight surgeon to become a member of a
multidisciplinary research team employing the most
sophisticated human centrifuge in the free world and
other acceleration platforms. Other research activities
encompass cold water survival and perceptual studies.
The incumbent also supervises a Navy subject pool, re-
views and coordinates research efforts involving the
use of human beings, provides interagency liaison for
programs using Navy acceleration platforms, and pro-
vides medical care for NADC's aviation community. In-
house research funds are available for approved inde-
Blue Angels. The Navy Flight Demonstration Team
will require a flight surgeon in January 1979. LT Ber-
nard Gipson, MC, USN, currently with the "Blues,"
can provide detailed information.
Anyone interested in any of these challenging billets
should call CDR Jim Black, MC, USN, BUMED Code
311-1, at Autovon 294-4390.
POSTDOCTORAL ASSOCIATESfflPS . . . Applications
are now being accepted for the postdoctoral research
associateship programs conducted by the National Re-
search Council of the National Academy of Sciences on
behalf of the Naval Medical Research and Development
Under the programs, postdoctoral biomedical engi-
neers and medical, biological, and behavioral scientists
participate in biomedical research projects conducted in
NMRDC laboratories. Awards, made on a competitive
basis, are tenable at five Navy facilities: the Naval
Medical Research Institute, Bethesda, Md.; the Naval
Aerospace Medical Research Laboratory, Pensacola,
Fla.; the Aircraft and Crew Systems Technology Direc-
torate, Naval Air Development Command, Warminster,
Pa.; the Naval Submarine Medical Research Labora-
tory, Groton, Conn.; and the Naval Health Research
Center, San Diego, Calif.
Areas in which the research associateships are
awarded are: experimental medicine, immunology,
undersea medicine, aerospace medicine, behavioral
sciences, biochemistry, biophysics, environmental
stress, microbiology, parasitology, virology, biomag-
netics, physiology, and radiation biology.
Candidates must hold an M.D., a D.D.S., or a Ph.D.
degree or the equivalent, and must be research
The National Research Council screens the candi-
dates' records, selects applicants, and approves the
scientific merits of laboratory projects and the creden-
tials of research advisors.
Applications must be postmarked no later than 15
Jan 1979 and must be received in the Council's Asso-
ciateship Office no later than 25 Jan 1979. Supporting
documents must be received by 12 Feb 1979.
For further details, write: Associateship Office (JH-
608-NI), National Research Council, 2101 Constitution
Ave., N.W., Washington, D.C. 20418.
Volume 69, November 1978
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